Smoking cessation support preferences among people released from smoke-free prisons in Queensland, Australia

Daily tobacco use is substantially more prevalent among Australians who experience incarceration (71%) compared to the general population (8.3%) (Australian Institute of Health and Welfare, 2024; Australian Institute of Health and Welfare, 2023). These high rates of tobacco use result in a disproportionate burden of smoking-related mortality and morbidity (Binswanger et al., 2014), and exacerbate the poor mental and physical health outcomes and social and financial disadvantage typically experienced by this population (Binswanger et al., 2014). In an attempt to mitigate the burden of tobacco smoking or second-hand smoke exposure among those who live or work in prisons, prison-based smoke-free policies have been implemented internationally (Binswanger et al., 2014; Spaulding et al., 2018). In Australia, total smoking bans - where no tobacco or e-cigarette use is permitted indoors or outdoors - apply to prisons in six of the eight states or territories, including Queensland. While these policies mandate smoking abstinence during incarceration (Spaulding et al., 2018; Puljevic et al., 2018), almost all individuals who smoked tobacco upon entry to prison relapse to smoking upon release, meaning that prison-based smoke-free policies typically result in short-term abstinence only (Puljević and Segan, 2018). For example, a Queensland-based study found that 72% of a sample of people who smoked upon entry to prison relapsed to smoking on the day of release and 94% resumed smoking within two months of release, despite 66% intending to remain abstinent post-release (Puljević et al., 2018).

A primary reason for these high rates of post-release smoking relapse is the limited availability of smoking cessation support during incarceration and upon release, leaving individuals unprepared to maintain smoking abstinence when re-entering the community (Puljević and Segan, 2018; Puljevic et al., 2019). While the general Australian public has access to a range of evidence-based smoking cessation interventions, such as nicotine replacement therapy (NRT, with subsidised nicotine patches available at a low cost through the pharmaceutical benefits scheme (PBS). The Pharmaceutical Benefits Scheme, 2023; Puljević et al., 2017), prescription medication (i.e. varenicline or bupropion, also PBS subsidised), and behavioural counselling (e.g. through Quitline telephonic smoking cessation counselling service) (Greenhalgh et al., 2022), the only forms of cessation support available in Queensland’s prison are nicotine lozenges (available for purchase) and free, unrestricted calls to Quitline (Puljevic et al., 2018). When the smoke-free policy was implemented in Queensland’s prisons, a free 12-week supply of nicotine patches was offered to everyone entering prison, but these were soon removed following reports of diversion; individuals were using patches to infuse tea leaves with nicotine, and then rolled these into cigarettes using Bible paper, nicknamed “teabacco” (Puljevic et al., 2018; Mitchell et al., 2019). Although this practice continued with nicotine lozenges (Fagerstrom, 2012), the lozenges remain available for sale in Queensland’s prisons.

People released from prison in Queensland are eligible for Quitline’s free Intensive Quit Support program, consisting of 12 weeks of NRT and weekly calls from Quitline (Cancer Council Queensland, 2019), but the program is not promoted in any way, and only one person released from prison has accessed the program in 2023. In Australia, probation is a community-based order that courts may use as an alternative to, or along with, a prison sentence, while parole is the conditional release of a person after they serve part of their sentence in a prison (Queensland Government, 2024). Of all people serving probation or parole orders in Queensland on 1 September 2017, the year that data collection for this study occurred, 21% had been released from full-time custody (Australian Bureau of Statistics, 2024). The lack of smoking cessation support for people who experience incarceration, both in prison and post-release, is a crucial missed opportunity to reduce high rates of smoking-related morbidity and mortality among this population (Binswanger et al., 2014; Puljević and Segan, 2018; Puljević et al., 2018; Puljević et al., 2017).

Current international literature in this area focuses on the views, implementation or consequences of prison-based smoke-free policies (Spaulding et al., 2018). We are aware of only one study investigating cessation support preferences among this population. An evaluation of a prison-based smoke-free policy implemented in Australia’s Northern Territory reported limited qualitative data on preferences for cessation support, with participants expressing preference for options other than NRT (e.g. sports programs), and unsupported quitting (“cold turkey”) (Hefler et al., 2016). We are unaware of any studies reporting preferences for cessation support delivered after release from prison. Investigating preferences for smoking cessation support in prison and post-release is important to ensure that any such support is acceptable among its target population, maximising uptake and effectiveness. As such, the aim of this investigation is to investigate previous use, awareness and preferences for various forms of cessation support among a sample of people recently released from smoke-free prisons in Queensland, Australia.

This study used data collected as part of a broader study investigating rates of smoking relapse among people recently released from smoke-free prisons in Queensland, Australia (Puljević et al., 2018). Ethical clearance was granted by Griffith University’s Human Research Ethics Committee (2015/581).

Participants were recruited from 12 Probation and Parole offices across South-East Queensland (Puljević et al., 2018). Survey development, participant recruitment and data collection methods have been described in detail previously (Puljević et al., 2018; Puljevic et al., 2019). Participants were eligible to take part in the survey if they:

• smoked tobacco daily on entry to prison;

• had been released from prison within the past two months, and for at least one full day;

• were on parole and reporting in-person to a Probation and Parole office; and

• had been incarcerated for longer than one week (to provide sufficient exposure to the smoke-free policy).

Parole office staff members identified potentially eligible participants and referred them to the primary researcher (CP). After the researcher provided a brief explanation of the study, participants who agreed to take part provided written consent. Surveys took approximately 20–30 min to complete and were administered verbally to mitigate literacy concerns. Participants were provided with a $20 supermarket voucher as a reciprocity payment.

The survey covered mental and physical health; incarceration history; socio-demographic characteristics; and tobacco and other drug use. Nicotine dependence was assessed using the Fagerström Test for Nicotine Dependence (FTND) (Puljević et al., 2018; Fagerstrom, 2012). The Motivation to Stop Scale (MTSS) was used to assess readiness to quit smoking (Kotz et al., 2013). Data from the Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA) were used to determine if participants lived in a disadvantaged area, indicated by postcode.

Those who reported not using NRT or using less than a week’s supply of NRT in prison (n = 45) were asked why. Those who reported being unlikely to use NRT post-release (n = 46) were asked why. All participants were asked what the one thing (i.e. motivating reason) is that would make them quit smoking, as an open-ended question. Qualitative responses for these three questions were categorised. Relevant survey questions are listed in the Supplementary file. Data were analysed using descriptive statistics.

Most participants were male (86%), aged ≥ 25 years (83%), and lived with other people who currently smoke (64%) in a disadvantaged area (70%; see Table 1). Participants had been incarcerated for a median of 14 weeks (interquartile range [IQR] 9–24 weeks), and out of prison for a median of 30 days (IQR 19–48 days) (Puljević et al., 2018). Nearly all (94%) had relapsed to daily tobacco smoking since release from prison, and were smoking a median of 10 cigarettes per day post-release (IQR 3–20).

A total of 36 participants reported using NRT before incarceration (32%), with patches the most commonly-used product (23%; Table 2). In total, 30 (26%) participants reported using nicotine lozenges in prison. Among those who did not use NRT during incarceration or used it for less than a week, the main reason reported was a lack of availability (27%). Other common reasons were preferring to quit cold turkey (20%), wanting to avoid unpleasant side effects from NRT (18%), or not wanting to be pressured by others to trade or give away their NRT (9%). After release, although awareness of being able to access subsidised NRT products was high (76%), only 24% of participants reported that they were likely to use NRT to quit smoking (Table 2). Again, a preference for going cold turkey (28%) or wanting to avoid unpleasant side effects (26%) were common reasons.

Although awareness of the ability to make free calls to Quitline in prison was relatively high (66%), only three participants used the service while in prison (<3%). Nearly half of participants (42%) agreed that a prison-based peer support group would have been helpful to cope with quitting smoking when entering prison, with a higher percentage (52%) agreeing that an equivalent community-based peer support group would be helpful to assist with maintaining smoking abstinence post-release. Fewer than a third of participants (30%) reported that they would find it helpful if their parole officer provided brief advice to quit smoking. The most commonly reported factor that would make participants consider quitting smoking was the impact of smoking on their health (55%).

This brief report describes past use of NRT and prescription smoking cessation medications, and preferences for various forms of smoking cessation support among a sample of people released from smoke-free prisons in Australia. We observed low levels of past NRT and/or prescription smoking cessation medication use, and found that a community-based peer smoking cessation support group was the most favoured form of cessation support.

Our findings show low levels of pre-incarceration smoking cessation medication use (16%), NRT use before (32%) and during (26%) incarceration, and perceived likelihood to use NRT in the future (24%). The most commonly cited reason for not using NRT during incarceration was lack of availability. The only form of NRT available in Queensland’s prisons is nicotine lozenges, and at the time of data collection, these cost AUD$14 per pack, a prohibitively high price for many people living in prisons. The second most common reason was preferring to quit cold turkey (20%), reflecting findings from previous Australian studies conducted among people experiencing mental illness (Meurk et al., 2016) or substance use disorders (Kelly et al., 2018) who often prefer to avoid NRT due to perceived ineffectiveness (Meurk et al., 2016; Kelly et al., 2018) or side effects such as nightmares and allergic reactions (Meurk et al., 2016). Other participants described not wanting to use NRT in prison to avoid pressure from others to trade or give away their NRT. While this peer pressure was more common when free nicotine patches were provided upon prison entry (Puljevic et al., 2018; Hefler et al., 2016), a previous study with this sample found that diversion of NRT to make teabacco from nicotine lozenges was a relatively common practice (Puljevic et al., 2018). A forensic analysis of this form of teabacco found that the product’s chemical constituents are notably less harmful than those in traditional combustible tobacco (Mitchell et al., 2019). As such, in the absence of any other form of in-prison smoking cessation support, we strongly recommend improved access to nicotine lozenges and government-subsidised forms of smoking cessation pharmacotherapy (varenicline, bupropion, nicotine patches) for those entering and leaving smoke-free prisons to promote smoking abstinence not only for the duration of their incarceration, but long-term (Puljević et al., 2018). This would align with Australia’s commitment to provide prison-based healthcare equivalent to that of the general community (Cumming et al., 2018). At present, despite this commitment, people in prison are barred from accessing low-cost, evidence-based government-subsidised smoking cessation medications through the PBS, further exacerbating existing disparities in physical-health outcomes compared to the general community (Cumming et al., 2018). We also recommend widespread promotion of Quitline’s Intensive Quit Support program for those being released from prison, such as through postcards inserted into exit packs. There would also be benefit in promoting awareness of the benefits of Quitline and NRT for those trying to quit smoking, perhaps via posters placed in probation and parole waiting rooms.

Our findings also support complementing NRT provision with peer smoking cessation support groups, both in prison and in the community. Of the various forms of smoking cessation support measured in our survey, this was the most favoured, both within prisons (42%) and post-release (52%). This recommendation is supported by findings from a recent US-based study, which found high levels of program attendance and quit attempts among 39 men who used tobacco and were due for imminent release from a prison in Arizona (Garver-Apgar et al., 2023). Furthermore, a systematic review of peer support programs for smoking cessation in disadvantaged groups found that these programs are effective at promoting cessation and for providing an empowering way to source social support for health issues (Ford et al., 2013; West et al., 1998; Williams et al., 2011). Peer social support may be particularly salient for this population who experience notably worse social-, financial-, and health-related outcomes compared to the general community, especially in the weeks immediately following release from custody (Kinner and Young, 2018). These peer support groups could be hosted by Probation and Parole offices, who already host various group-based support programs (e.g. for anger management). In Australia, there are no regulations restricting these kinds of group programs, unlike in the USA, where associations with known felons are prohibited. Support for brief cessation advice from a parole officer was low (30%), possibly due to distrust of prison authorities typical among people who have experienced incarceration (Crewe, 2011).

This study is, to the best of our knowledge, the first to investigate preferences for smoking cessation support among people released from smoke-free prisons. This study has some limitations. First, we recruited a relatively small (n = 114) convenience sample from one geographic area (South-East Queensland), limiting both statistical power and generalisability. Replication is required. Second, reliance on self-report may lead to recall bias and underreporting of illegal behaviours, and missing data. However, we are unaware of any other way of measuring individual preferences and attitudes. Third, when participants were asked what the one thing (i.e. motivating factor) is that would make them quit smoking, they were unable to select a combination of factors, which may have been a preferred choice for some. Furthermore, the survey did not cover all available forms of smoking cessation support (e.g. individual behavioural counselling, e-cigarettes, digital interventions). Fourth, the data were collected eight years ago in 2017, with the delay in reporting these results being partly due to the COVID-19 pandemic. However, the context of smoke-free prisons remains unchanged in Queensland; for example, nicotine lozenges were and still are the only form of in-prison smoking cessation support available.

This study investigated past use and perceptions of various forms of smoking cessation support among a sample of people released from smoke-free prisons, finding low rates of past NRT and/or prescribed smoking cessation medication use, and a preference for peer-based smoking cessation support. These findings highlight a need for further smoking cessation support, including subsidised pharmacotherapy and complementary peer supports both in prison and post-release, to promote smoking cessation among this population marked by poor physical health and social disadvantage.

Statements.

The authors would like to acknowledge and thank participants for sharing their experiences, and probation officers who assisted in recruiting participants.

Statement of Ethics: Ethical clearance was granted by Griffith University's Human Research Ethics Committee (2015/581).

Conflict of Interest Statement: The authors have no conflicts of interest to declare.

Funding Sources: Funding for this study was provided by the Griffith University School of Criminology and Criminal Justice. Dr Cheneal Puljević is supported by a Discovery Early Career Researcher Award from the Australian Research Council (DE230101131). Dr Dominique de Andrade is supported by a Discovery Early Career Researcher Award from the Australian Research Council (DE230101466).

Data Availability Statement: The data that support the findings of this study are not publicly available due to their containing information that could compromise the privacy of research participants but are available from the corresponding author (CP) if prior ethics approval is received.

The supplementary material for this article can be found online.